Winning the War for Independence: The Independence at Home Act

What will it take to get our nation to prepare for the Age Wave and the chronic disease epidemic that is already here? What do we have to do to make home-based care a fundamental priority for government, healthcare, and industry? And if we’re not going to drive care to the home and to the consumer in this round of healthcare reform, when exactly will we get to it?

Maybe you can tell I’m feeling a little impatient and impertinent.

For the past 18 months (indeed for the past 18 years!), I have enlisted in a campaign to change our ways of thinking about healthcare and long term care. In the early 1990s, while working for Paul Allen’s think-tank, Interval Research, we did a project called “ElderSpace” that showed great promise to use technologies to help improve nursing homes—or even better, to help people to age-in-place from their own homes. And for the past 10 years at Intel, we’ve done pilot after pilot of home-based technologies that show enormous promise for helping seniors to live with comfort, independence, and dignity from wherever they choose, even in the midst of chronic conditions and injuries that often emerge as we grow older.

While we’ve won small battles here and there, we’ve continued to lose the war to an army of stubborn assumptions and cultural expectations that healthcare has to be done in institutions like hospitals and care facilities, instead of homes and neighborhoods. Trip after trip to D.C., speech after speech to every association that will listen, meeting after meeting with members of Congress, I hear the same old tunes: “we need to focus on the doctors and the hospitals first”…or “let’s maybe do a small pilot of home based care”…or “we’ll get to that idea at some point in the future.” And I watch the debate and important legislative agendas get hijacked by public options, Congressional Budget Office scores, and whatever headlined hot topic can raise ratings and the national blood pressure for a news cycle or two.

No, no, NO! No more delays or distractions! No more blue ribbon commissions, 10-year studies, “small pilots,” or rainchecks to get to this topic some other day. The time is now. The need is now. The opportunity is now. And we need leadership to reinvent our care paradigm, not excuses, avoidance, and obfuscation. We need a revolutionary war for independence from clinic-centric care models—a clean break from our 200 year old hospital-centric tradition—that gives us new ideas, new freedoms, and new opportunities. Okay, okay, maybe I’m overdoing it here…maybe that’s too strong of a metaphor…but after so many years in the trenches on this issue and getting the run-around or outright silence, some loud and revolutionary language may be in order!

But there is some small progress—some reason for hope.

Back in May, Senator Ron Wyden of Oregon and Congressman Ed Markey of Massachusetts introduced the Independence at Home Act (S.1131) as amendments to healthcare reform legislation in the Senate and House. The Independence At Home Act has now been included in the recently combined version of the House bill (the 1990-page version that I am still trying to wade through) which is rumored to hit the floor for a vote as early as Saturday, if the Congressional Budget Office scoring comes in soon.

You can read the full text of the bill and track its progress at the Govtrack site. The American Academy of Home Care Physicians has a summary here. And I also like the American Academy of Nurse Practitioners summary located here. But the gist of this act, as its name suggests, is that it assumes the home as the primary locus of care from the outset for Medicare patients who are dealing with multiple chronic conditions. It rewards coordinated, interdisciplinary care teams for delivering high quality care in the home to some of the most frail, vulnerable, and expensive patients in our system. The bad news is that the Act has been reduced from its original version to only do this as a Medicare demonstration pilot in 13 states (more pilots!), but the good news is that there are mechanisms to continue and scale up the model if it delivers upon the promise of high quality care at lower costs. Most important to me is that it provides care for seniors and chronic disease patients from the comfort of their own homes, where they have the best chances at remaining independent, recovering from illness, being free from infection, avoiding additional hospitalizations, and having social support from friends and family in the community.

So I am cautiously optimistic. On the one hand, 18 years of this fight has made me a little jaded because the final bill, with all of the details to be ironed out, has not been voted upon and signed yet. And our clinic-centric mentality has proven to be a strong gravity from which our culture has yet to reach escape velocity. But on the other hand, Independence at Home has so many of the most important, game-changing elements of healthcare reform that we really need to make happen nationwide: care coordination, interdisciplinary care, payment for outcomes, cost savings, quality improvements, and a focus on the home as a key place for care delivery. And with examples that already show its effectiveness (the Veteran’s Administration has been doing a similar model with their Home Based Primary Care program for years—which I will blog about soon), Independence at Home, while a small step on the healthcare reform journey, may end up being a huge step for humankind.

So send your impatient and impertinent cards, letters, and emails to your Congressional members and tell them to keep Independence at Home alive and well in the health reform bill…and to make home based care a national priority now, not later. Our swiftly aging planet needs it.